Steven B. Leder

Clinical Utility of the 3-ounce Water Swallow Test

The 3-ounce water swallow test is frequently used to screen individuals for aspiration risk. Prior research concerning its clinical usefulness, however, is confounded by inadequate statistical power due to small sample sizes and varying methodologies. Importantly, research has been limited to a few select patient populations, thereby limiting the widespread generalizability and applicability of the 3-ounce test. The purpose of this study was to investigate the clinical utility of the 3-ounce water swallow test for determining aspiration status and oral feeding recommendations in a large and heterogeneous patient population. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed in conjunction with the 3-ounce water swallow test on 3000 participants with a wide range of ages and diagnoses. A total of 1151 (38.4%) passed and 1849 (61.6%) failed the 3-ounce water swallow test. Sensitivity of the 3-ounce water swallow test for predicting aspiration status during FEES = 96.5%, specificity = 48.7%, and false positive rate = 51.3%. Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results = 96.4%, specificity = 46.4%, and false positive rate = 53.6%. Passing the 3-ounce water swallow test appears to be a good predictor of ability to tolerate thin liquids. However, failure often does not indicate inability to tolerate thin liquids, i.e., low specificity and high false-positive rate. Use of the 3-ounce water swallow test alone to make decisions regarding safety of liquid intake results in over-referral and unnecessary restriction of liquid intake for nearly 50% of patients tested. In addition, because 71% of participants who failed the 3-ounce water swallow test were deemed safe for an oral diet, nonsuccess on the 3-ounce water swallow test is not indicative of swallowing failure. The clinical utility of the 3-ounce water swallow test has been extended to include a wide range of medical and surgical diagnostic categories. Importantly, for the first time it has been shown that if the 3-ounce water swallow test is passed, diet recommendations can be made without further objective dysphagia testing.

Fiberoptic Endoscopic Evaluation of Dysphagia to Identify Silent Aspiration

Abstract. The traditional bedside dysphagia evaluation has not been able to identify silent aspiration because the pharyngeal phase of swallowing could not be objectively assessed. To date, only videofluoroscopy has been used to detect silent aspiration. This investigation assessed the aspiration status of 400 consecutive, at risk subjects by fiberoptic endoscopic evaluation of swallowing (FEES). Our study demonstrated that 175 of 400 (44%) subjects were without aspiration, 115 of 400 (29%) exhibited aspiration with a cough reflex, and 110 of 400 (28%) aspirated silently. No significant differences were observed for age or gender and aspiration status. The FEES, done at bedside, avoids irradiation exposure, is repeatable as often as necessary, uses regular food, can be videotaped for review, and is a patient-friendly method of identifying silent aspiration.

Aspiration Risk After Acute Stroke: Comparison of Clinical Examination and Fiberoptic Endoscopic Evaluation of Swallowing

AbstractAspiration is an important variable related to increased morbidity, mortality, and cost of care for acute stroke patients. This prospective systematic replication study compared a clinical swallowing examination consisting of six clinical identifiers of aspiration risk, i.e., dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow, with an instrumental fiberoptic endoscopic evaluation of swallowing (FEES) to determine reliability in identifying aspiration risk following acute stroke. A referred consecutive sample of 49 first-time stroke patients was evaluated within 24 hours poststroke, first with the clinical examination followed immediately by FEES. The endoscopist was blinded to results of clinical testing. The clinical examination correctly identified 19 subjects with aspiration risk, when compared with the criterion standard FEES, but incorrectly identified 3 patients as having no aspiration risk when they did. The clinical examination incorrectly identified 19 subjects with aspiration risk but determined correctly no aspiration risk in 8 patients who did not exhibit aspiration risk on FEES. Clinical examination sensitivity = 86%; specificity = 30%; false negative rate = 14%; false positive rate = 70%; positive predictive value = 50%; and negative predictive value = 73%. It was concluded that the clinical examination, when compared with FEES, underestimated aspiration risk in patients with aspiration risk and overestimated aspiration risk in patients who did not exhibit aspiration risk. Careful consideration of the limitations of clinical testing leads us to believe that a reliable, timely, and cost-effective instrumental swallow evaluation should be available for the majority of patients following acute stroke.

Fiberoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients.

Abstract. The purpose of this study was to investigate the incidence of aspiration following extubation in critically ill trauma patients. This prospective pilot study included 20 consecutive trauma patients who required orotracheal intubation for at least 48 hours. All subjects underwent a bedside transnasal fiberoptic endoscopic evaluation of swallowing at 24 ± 2 hr after extubation to determine objectively aspiration status. Aspiration was defined as the entry of a blue dyed material into the airway below the level of the true vocal folds, with silent aspiration occurring in the absence of any external behavioral signs such as coughing or choking. Aspiration was identified in 9 of 20 (45%) subjects and 4 of these 9 (44%) were silent aspirators. Therefore, silent aspiration occurred in 20% of the study population. Eight of the 9 (89%) aspirating subjects resumed an oral diet from 2–10 days (mean, 5 days) following extubation. All subjects had no evidence of pulmonary complications. It was concluded that trauma patients after orotracheal intubation and prolonged mechanical ventilation have an increased risk of aspiration. An objective assessment of dysphagia to identify aspiration may reduce the likelihood of pulmonary complications after extubation.

Fiberoptic Endoscopic Evaluation of Swallowing in the Pediatric Population

Objective To investigate the diagnostic and rehabilitative usefulness of routine fiberoptic endoscopic evaluation of swallowing (FEES) in the pediatric population.

Investigation of the causal relationship between tracheotomy and aspiration in the acute care setting.

Objective To investigate the causal relationship, if any, between tracheotomy and incidence of aspiration in the acute care setting.

Longitudinal voice quality changes following isshiki thyroplasty type I: The yale experience†

Longitudinal voice quality changes following Isshiki thyroplasty type I were investigated in a group of 18 patients exhibiting unilateral vocal fold paralysis. Thyroplasty type I medializes the paralyzed fold by using a Silastic® implant for external lateral compression of the abducted fold. No perioperative complications were experienced. We observed significantly higher voice fundamental frequency, significantly louder voice intensity, and significantly longer maximum phonation time, both immediately following phono‐surgery and up to 3 months postoperatively. Surgical refinements of thyroplasty type I are described.

The contribution of aryepiglottic constriction to “ringing” voice quality—A videolaryngoscopic study with acoustic analysis*

Summary Fiberscopic video laryngoscopy was performed on five professional singers to determine the presence or absence of aryepiglottic narrowing as a function of voice quality. Each sang “Happy Birthday” and parts of the “Star Spangled Banner” in six different voice qualities: speech, falsetto, sob (a low larynx with a vocal tract expanded by relaxing the middle constrictors), twang, belting, and opera. Several features were found to be common among the subjects and related to specific qualities. Aryepiglottic constriction was present in all singers in twang, belting, and opera qualities. Spectrographic analysis related the constriction to the presence of the “singers formant.” The presence of this type of constrictive behavior will require further research to ascertain the possible benefits to those for whom a louder voice is essential and to understand the relationship of this constrictive maneuver to the natural closure functions of the larynx.

Use of fiberoptic endoscopic evaluation of swallowing (FEES) in patients with amyotrophic lateral sclerosis.

This study investigated the use of fiberoptic endoscopic evaluation of swallowing (FEES) to both diagnose pharyngeal dysphagia and make treatment recommendations in 17 consecutive patients with a new diagnosis of amyotrophic lateral sclerosis (ALS) and complaints of dysphagia. Ten of 17 (59%) patients exhibited pharyngeal dysphagia with aspiration or aspiration risk with clear liquids, i.e., 5 of 8 (63%) limb and 5 of 9 (56%) bulbar. If depth of bolus flow was a problem, thickened liquids and single, small bolus sizes were recommended. If bolus retention was a problem, a small clear liquid bolus after each puree or solid bolus was recommended to aid pharyngeal clearing. Five of 17 (30%) patients required multiple FEES evaluations because of disease progression. For the first time in patients with ALS, FEES was shown to be successful in assessing preswallow anatomy and physiology, diagnosing pharyngeal dysphagia, and providing objective data for appropriate therapeutic interventions to promote safer oral intake. Visual biofeedback provided by FEES was successful for both patient and family education and to investigate individualized therapeutic strategies that, if successful, can be implemented immediately. Serial FEES allows for objective monitoring of dysphagia symptoms and timely implementation of diet changes and/or therapeutic strategies to continue safer oral intake and maintain optimum quality of life.

Videofluoroscopic evaluation of aspiration with visual examination of the gag reflex and velar movement

Abstract. The purpose of the present study was to investigate the relationship between prevalence of aspiration as determined by videofluoroscopic evaluation and prevalence of the gag reflex and velar movement as determined by direct visual examination. One hundred adult patients underwent a videofluoroscopic evaluation of aspiration with either an esophagram (n = 31), upper gastrointestinal series (n = 18), small bowel series (n = 23), or modified barium swallow procedure (n = 28), and concomitant evaluation of the gag reflex and velar movement on phonation. All studies were performed using the lateral, upright position, and all patients drank at least 5 cc of single contrast barium. Aspiration was defined as penetration of material below the level of the true vocal folds. A normal gag reflex and normal velar movement on phonation were observed in 14 of 15 (93%) patients who exhibited objective documentation of aspiration with videofluoroscopy. Conversely, 19 of 20 (95%) patients without a gag reflex were observed with videofluoroscopy to be without aspiration. Normal velar movement on phonation was observed in 99 of 100 (99%) patients. There was no significant age difference between patients with or without a gag reflex. No relationship was found between the prevalence of aspiration and the gag reflex or velar movement on phonation. It was concluded that the presence of a gag reflex does not protect against aspiration, and the absence of a gag reflex does not predict aspiration.